A Midfoot Misstep That Needed Surgery

We break down a real clinic case where a simple misstep leads to a suspected Lisfranc injury and a fast track from urgent imaging to surgical care. We share the exam and X-ray clues that help us spot midfoot instability early, plus what recovery often looks like after fixation.
• case presentation after a plantar-flexion misstep with a pop and immediate inability to weight bear
• key exam findings including diffuse midfoot oedema, focal medial midfoot tenderness, and pain with forefoot compression and rotation
• X-ray alignment changes that raise concern for Lisfranc disruption and why CT helps define the injury
• Lisfranc ligament anatomy and why plantar arch bruising can be a high-value clinical sign
• when non-operative care may fail and why surgical referral is common with widening and instability
• post-op course including splinting, casting, strict non-weight bearing, and gradual return in a walking boot with physical therapy
• realistic healing timeline, persistent swelling, and practical counselling points for patients

Transcript

Podcast Welcome And Purpose

SPEAKER_00 0:07

Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves.

Case Setup And Mechanism Of Injury

SPEAKER_00 0:46

Hello, everyone, and welcome back to the podcast. My name is Chuck Dowell. I'm one of the PAs and co-hosts of the podcast. Today we're doing a case. Um so this was a 24-year-old gentleman who I saw in clinic. Uh he complained of one day of increasing pain within his foot. He states he was attempting to step over a dog gate that was at the top of the stairs. Um he misstepped, landed on his foot in a bit of a plantar flex position, uh, immediately had pain, felt a popping sensation, was unable to weight bear, uh, ended up going to the emergency room where x-rays were taken. The x-rays were concerning for a ligamentous injury within the foot. He was then placed into a splint and uh told to remain on crutches non-weight bearing, and a CT scan was ordered. Um he came in the following day to see me in the orthopedic urgent care for evaluation regarding this. So, again, if you kind of take a minute, if you're listening to this case, if you're following along on YouTube, I do have the images up um as part of the case, so you can kind of see the images that he did present with. But what's your immediate thoughts? He comes in, he is stepping over a gate in a slightly planner flex position. Uh, he lands wrong and immediately has significant pain within the foot area.

Exam Findings That Raise Suspicion

SPEAKER_00 2:08

So, on examination, um, he did have um noticeable edema diffusely throughout the midfoot area. Uh, he didn't have any significant echimosis noted. Uh, there was significant tenderness noted throughout the uh medial midfoot area, especially over the dorsal aspect within the midfoot, but some did extend to the planar aspect of the midfoot and medial arch area. He had decreased active and passing range of motion due to the acute injury. Um, he had increasing pain with kind of compression of his metatartial heads and supination protonation caused significant increasing midfoot pain. So, again, with this kind of presentation and exam, what are your initial thoughts?

X-Ray Clues For Lisfranc Injury

SPEAKER_00 2:48

So, those of you that are following on on YouTube, you can see that the initial x-rays, including kind of an AP and lato of the foot, do show some concerns of widening within that uh first and second uh proximal metatarsal junction, um, and to show that there is loss of alignment between that medial side of that second metatarsal and that intermediate cuneiform. And typically this represents concerns for possible Lis Frank injury. Uh the lateral view uh did show, um, if we zoom in here a little bit, that he did have that proximal aspect of that first metatarsal is slightly dorsally um displaced, which sometimes can happen uh with that uh Lis Frank type injury as well. Again, secondary to this acute injury and his x-ray showing that there was widening of that area, the concern was this likely would not be able to be treated non-surgically or non-operatively, and he was referred to one of our foot and ankle surgeons.

Lisfranc Anatomy And Plantar Bruising

SPEAKER_00 3:48

So when we're talking about Lis Franc injuries, these are um frequent injuries. The Liz Franc is uh a ligament that attaches between the I apologize. The Liz Franc is an interosseous ligament that goes from the medial cuneiform to the second and or the base of the second metatarsial. So if we look at our normal anatomy here, um you can see that medial cuneiform and that base of the second metatarsial, uh, there's the dorsal aspect of that ligament. What a lot of us may get confused at is that oftentimes it's the planar aspect of this ligament that is the true Lis Frank injury. And these patients often present with some planar ecamosis. So again, if you're following along on the YouTube channel, you can see the picture here shows there's uh ecomotic changes within that medial arch area. The planar ecemosis can be um fairly significant and indicative of a Lis Frank injury. So again, if somebody comes in with an acute injury to the midfoot or the foot area and they do show signs of this planar ecemosis, you could think possible rupture of their medial arch or plantar fascia, but you could also think pathognomonic for possible Lis Franc injury. So again, the plantar aspect of that ligament is the most common one that's injured and top typically what causes that plantar ecamosis. That goes from that medial cuneiform to that second and third metatarsal proximal aspect. The Lis Franc is a critically stabilizing ligament between that first and second metatarsal joint. It does maintain the midfoot arch. It does typically tighten up within a pronation and abduction position. And you have to remember that is a complex of ligaments. So oftentimes when we see an injury just to that ligament, it's not just to that ligament, but oftentimes we'll have fractures or widening between the ligaments or the intermetatarsal uh ligaments of that second, third, third, fourth, and sometimes even that fourth and fifth. In our particular patient, it was hard to tell based upon the imaging, but it does look like he has a small fracture here at the proximal aspect of his third metatarsal and possibly even of his fourth metatarsal.

Surgery, Immobilisation, And Recovery Timeline

SPEAKER_00 6:13

So he ended up going to surgery. You can see here the operative uh photos are post-operative photos that were taken. Uh, they did put uh plate fixation in there to kind of recorrect that anatomy and also screw fixation because there was an effect of that third metatarsal going to that lateral cuneiform. Uh, post-operatively, oftentimes these are non-weight bearing. So this patient was placed in a splint initially for two weeks, came back and saw our orthopedic surgeon, and then the swelling had reduced at that point and was then transitioned to a cast. The cast will remain on for about six weeks. He's strict non-weight bearing when in the cast. Um, after six weeks uh to eight weeks of non-weight bearing, uh, they can then progress uh to weight-bearing activities and a walking boot. If we're treating this non-operatively, typically we do immobilize these with a cast. Uh, the cast immobilization is usually for eight weeks. Um you can consider you know different uh options in different patients if they don't and or have an ability to uh not be fully non-weight bearing. You can consider a cast boot and maybe a knee scooter for those patients. Uh, typically they do quite well, but the healing time is quite long for these. So you have to you know discuss with patients that oftentimes the foot remains swollen for longer than most things because it's kind of at the bottom of the hill. And so oftentimes the swelling accumulates in that area. And because of that, and because it's a weight-bearing joint, it often takes longer to heal. So these can take six to eight months, if not plus four healing. Uh, this patient actually at three months was doing well. He had progressed to weight-bearing activities in the walking boot, was starting physical therapy at that time, and was progressing quite

Clinical Takeaways And Closing

SPEAKER_00 7:59

well. So, again, if you have a patient that comes into clinic, um, these are quite impressive typically. Most of the time, the patient will come in with a lot of edema throughout that midfoot area, fairly significant pain, difficulty, or inability to weight bear within the area. And then again, look for that path of pneumonic changes with that medial planter uh bruising that may uh occur. Uh again, I hope you enjoyed this case. Uh, thanks for listening, and we'll talk to you on the next one.